Look externally, Evaluate 3-3-2 rule, Mallampati score, Obstruction, Neck MobilityBeard, Obese, No teeth, Elderly, Sleep Apnea / SnoringRestricted mouth opening, Obstruction, Distorted airway, Stiff lungs or c-spineSurgery, Hematoma, Obesity, Radiation distortion or other deformity, Tumor*

Assess for: Difficult laryngoscopyDifficult BVMDifficult extraglottic deviceDifficult cricothyrotomy

Is non-invasive ventilation (CPAP/BiPAP) an option? Is the patient DNI status? Has patient/family consented, if applicable?

Consider the indication for intubation

Equipment Use Broselow tape for sizes in pediatrics

Drugs

Atropine .02 mg/kg IV or IM (min 0.1 mg, max 1 mg) For infants, especially if receiving succinylcholine

Lidocaine 1.5 mg/kg TBW for reactive airways or increased ICP

Fentanyl 3 mcg/kg TBW if high BP a concern (aneurysms, dissections, high ICP, severe CAD)

≥ 3 min or 8 deep breaths with face mask; O2 regulator turned all the way upIf inadequate saturation with NC+facemask: use NIV or BVM with PEEP valve If pt too agitated for preoxygenation: ketamine induction, preox, then paralyze

Preoxygenate with high-flow oxygen

Check for dentures Dentures in for bag mask ventilation, out for laryngoscopy

Position patientAuditory meatus to suprasternal notch (sheets under neck / occiput / shoulders)Patient's head to operator's lower sternum (bed height)**Torso angle of 30° recommended, especially in obesity and upper GI bleed

IV access Two lines preferable

Laryngoscopy handles - verify power At least two

Suction under patient's shoulder - verify function If suspected soiled airway (blood, vomitus, secretions), suction under each shoulder

Laryngoscopy blades - verify bulbs Curved and straight / One size larger, one size smaller

Oral airways Size: Angle of mouth to tragus of ear (usually 80, 90, or 100 mm in adults)

Nasal airways Size: Tip of nose to tragus of ear (usually 26 Fr/6.5 mm, 28/7, or 30/7.5 in adults)

Colorimetric capnometer To be used if continuous not available or not functioning

Endotracheal tubes - verify cuff function Variety of sizes ( ≥ 8.0 mm preferred in adults to facilitate ICU care)

ETT stylet Straight to cuff, 35 degrees**

ETT securing device Tape if no device available

Gum elastic bougie

Difficult airway equipment Cricothyrotomy tools / video laryngoscope / optical stylet fiberoptic scope / Magill forceps if suspected foreign body

Pretreatment agents, if applicablePretreatment agents are always optionalGive as bolus 3 minutes prior to induction, except for fentanyl, which should be the final pretreatment agent, and should be given over 30-60 seconds.

5 liters per minute to augment preoxygenation, then ≥15 liters per minute post-induction to facilitate apneic oxygenation Nasal cannula

Ambu bag connected to oxygen Size: approximate nasal bridge, malar eminences, alveolar ridge / Err larger

LMA with lubricant and syringe

Monitoring equipmentECGPulse oximetryBlood pressureContinuous end-tidal capnography - verify function with test breath

RSIvs.

Awake

Prepare for failureof intubation and

failure of ventilationAirwayattempt

Post-intubation management

Plan B/C/D: Change patient position, blade,

modality or operator

Awake approach preferred whenLess urgent intubation

More difficult airway featuresLow risk of vomiting

Ventilate

Bag/mask or LMA

see bottom of page 2for awake technique

Supraglottic Airway

Cricothyrotomy

Discuss plan A, B, C, D with teamEquipment for plan A, B, C, D at bedside

see bottom of page 2 for cricothyrotomy technique; mark membrane prior to airway attempt if anticipated

Determine airway management strategy

EDICT Emergency Department Intubation ChecklisT

Preparation

EDICT Emergency Department Intubation ChecklisT

pg. 1

❑ Glycopyrolate 0.2 mg or Atropine .01 mg/kg glyco preferred, ideally given 15 min prior to next step❑ Suction then pad dry mouth with gauze❑ Nebulized Lidocaine without epi @ 5 lpm ideally 4 cc of 4% lidocaine but can also use 8 cc of 2% lidocaine❑ Atomized Lidocaine sprayed to oropharynx especially if unable to give full dose of nebulized lidocaine❑ Viscous Lidocaine lollipop 2% viscous lido on tongue depressor❑ Preoxygenate ❑ Position ❑ Restrain prn ❑ Switch to nasal cannula❑ Lightly sedate with Versed 2-4 mg or Ketamine 20 mg aliquots q 2 min❑ Intubate awake or place bougie, then paralyze, then pass tube

Awake Intubation Technique

R. Strayer / S. Weingart / P. Andrus / R. Arntfield Mount Sinai School of Medicine / v13 / 7.8.2012 *From Walls RM and Murphy MF: Manual of Emergency Airway Management. Philadelphia, Lippincott, Williams and Wilkins, 3rd edition, 2008; with permission.**From Levitan RM: Airway•Cam Pocket Guide to Intubation. Exton, PA, Apple Press, 2005; with permission.

RSI or Awake Technique

Paralytic agentSuccinylcholine 2 mg/kg IV 4 mg/kg IM TBWRocuronium 1.2 mg/kg IBWVecuronium 0.3 mg/kg IBW if roc unavailable

Contraindications to succinylcholineHistory of malignant hyperthermiaBurn or crush injury > 5 days old

Stroke or spinal cord injury > 5 days oldMS, ALS, or inherited myopathy Known hyperkalemia (absolute)

Renal failure (relative)Suspected hyperkalemia (relative)

Normal saline flushes

Phenylephrine For peri-intubation hypotension100 mcg IV push as needed

Personnel MD / RN / RT

Post-intubation settings discussed

A/CFiO2 100% – titrate down over time to SpO2 95%RR 18 [Asthma/COPD: 6-10]TV 8 mL/kg – use ideal body weight [6 mL/kg if sepsis / prone to lung injury]I/E 1:2 [Asthma/COPD 1:4 - 1:5]Inspiratory Flow Rate 60-80 L/min [Asthma/COPD 80-100 L/min]PEEP 5 cm H20 [CHF 6-12→watch blood pressure] [PEEP 0 in Asthma/COPD]

End-tidal CO2 if using colorimetric – bright yellow with six breathsEsophageal detection device should aspirate without resistence if ETT in tracheaBougie hold-up test - see belowRepeat visualization using direct laryngoscopy or alternate deviceAuscultation

Verify tube placement

Secure ETTRecord position at lips Adults: approx 21 cm (female) or 23 cm (male)Pediatrics: approximately ETT size x 3

Portable chest radiograph

Head of bed to 30-45 degrees, higher if very obese

Orogastric or nasogastric tube

Adjust ETT cuff pressureAdjust to minimum pressure required to abolish air leak - usually 15-25 mm Hg by endotracheal tube cuff manometer In-line heat-moisture exchanger

In-line suction

Blood gas within 30 minutes post-intubation

Adjust RR (not TV) to appropriate pH and pCO2Keep pH > 7.1 for permissive hypercapniaUse incremental FiO2/PEEP chart for oxygenationKeep plateau pressure < 30 cm H20pCO2 is at least ETCO2 but may be much higher Foley catheter

Dislodgement – check EtCO2 waveform, repeat laryngoscopyObstruction – check for high PIP, suction secretionsPneumothorax – breath sounds / lung sliding on ultrasound, repeat CXREquipment failure – disconnect from vent and bagStacking breaths / auto-PEEP - bag slowly, push on chest to assist prn

Bougie hold-up test: gently advance intubating stylet through ETT No resistance @ 40 cm: likely esophageal Resistance @ 26-40 cm (usually <30 cm): likely tracheal and patent Resistance @ less than 25 cm: likely clogged tube

Watch for post-intubation complications

Fentanyl and ketamine are least likely to cause or worsen hypotension.

Opioid then sedative boluses/drips

Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hourMorphine 0.1 mg/kg bolus then .1 mg/kg/hourPropofol 0.5 mg/kg bolus then 15 mcg/kg/minMidazolam 0.05 mg/kg bolus then .025 mg/kg/hourLorazepam 0.04 mg/kg bolus then .02 mg/kg/hourKetamine 1 mg/kg bolus then 1 mg/kg/hour

These are starting doses - reassess frequently and rebolus/titrate upward as needed.

In the just intubated phase, especially if transport and procedures are imminent, aggressively analgese and sedate to a RASS† score of -4 to -5. In the stable on the vent stage, titrate down sedation and use opioids to target a RASS score of -1 to -2. Avoid re-paralysis.

†Richmond Agitation Sedation Scale

Induction agent

Etomidate 0.3 mg/kg TBWPropofol 1.5 - 3 mg/kg IBW+(.4)(TBW)Ketamine 2 mg/kg IV or 4 mg/kg IM IBWMidazolam 0.2 - 0.3 mg/kg TBWThiopental 3- 6 mg/kg TBW

Reduce dose if hypotensive

Verify that airway equipment is ready for the next patient

1. Vertical incision, palpate membrane2. Blind horizontal incision through membrane3. Blind finger through membrane into trachea4. Bougie along finger into trachea5. Lubricated 6.0 mm ETT or tracheostomy tube via bougie

Post-Intubation Care

Cricothyrotomy Technique

EDICT Emergency Department Intubation ChecklisT

pg. 2